Jonjev Z, Redzek A, Radovanović N
Institut za kardiovaskularne bolesti, Univerzitetska klinika za kardiovaskularnu, hirurgiju, Sremska Kamenica.
Med Pregl. 2000 Jul-Aug;53(7-8):373-7.
The aim of this study was to evaluate long-term results after myocardial revascularization in patients with diffuse and distal coronary disease, and to compare this procedure with the classical approach--indirect myocardial revascularization (revascularization without endarterectomy).
This retrospective study was done in the period of three years, and includes patients operated between January 1, 1985 and December 31, 1990 at the University Clinic of Cardiovascular Surgery, Novi Sad. 500 patients were included and two groups were made. The investigated group consisted of 251 patients with endarterectomy and control group of 249 patients without endarterectomy. Other parameters (age, gender, preoperative hemodynamic parameters etc.) were practically the same.
Postoperative mortality (PM) during immediate 30 postoperative days was 4.64% in the investigated group, and 1.97% in the control group (total PM = 2.66%). The main causes of death were cardiac (3.74%), and the rest of them were respiratory, renal and cerebral. The highest postoperative mortality according to the localization of endarterectomy was left artery descendent (LAD) in the position of the first septal artery (36.36%). The follow-up study included 500 operated patients. The mean follow-up period was 9 years (0-13 years). Cumulative survival curve and postoperative myocardial infarction curve made by Wilcocxon (Gehan) and Kaplan-Meier methods showed no statistically significant difference between groups after 13 years of follow up. Lower incident of new angina was found in the investigated group (p < 0.01). Most of patients show good physical condition, well toleration of the stress test (Bruce protocol) and no significant impairment of ejection fraction.
Despite its long history and development, endarterectomy of coronary arteries is one of the most controversial methods in cardiac surgery. Application of this method was very restrictive mostly because its complexity and very controversial results from one institution to another. Endarterectomy of the first septal artery has the highest operative risk, but it is the method of choice in full revascularization of this region. Despite higher operative mortality, the immediate and long term results of this study show that endarterectomy of the coronary arteries is a method with very acceptable operative risk.
Endarterectomy is a good and effective method for direct myocardial revascularization in cases with diffuse coronary disease. It is the best procedure for revascularization of the septum. The number of endarterectomies and low ejection fraction are independent predictors for early and long-term mortality. Endarterectomy is also a method of choice in patients with low ejection fraction and poor coronary bed. Frequent and repeated application of angioplasty, higher incidence of diffuse and distal coronary disease and no available donors for heart transplantation will increase the application of this method. In the future we expect further improvement and complete affirmation of endartrectomy of coronary arteries.
本研究的目的是评估弥漫性和远端冠状动脉疾病患者心肌血运重建后的长期结果，并将该手术与经典方法——间接心肌血运重建（不进行动脉内膜切除术的血运重建）进行比较。
这项回顾性研究历时三年，纳入了1985年1月1日至1990年12月31日在诺维萨德大学心血管外科诊所接受手术的患者。共纳入500例患者，分为两组。研究组由251例行动脉内膜切除术的患者组成，对照组由249例未行动脉内膜切除术的患者组成。其他参数（年龄、性别、术前血流动力学参数等）实际相同。
研究组术后30天内的术后死亡率（PM）为4.64%，对照组为1.97%（总PM = 2.66%）。主要死亡原因是心脏原因（3.74%），其余为呼吸、肾脏和脑部原因。根据动脉内膜切除术的部位，术后死亡率最高的是第一间隔动脉位置的左冠状动脉前降支（LAD）（36.36%）。随访研究包括500例接受手术的患者。平均随访期为9年（0 - 13年）。采用Wilcocxon（Gehan）法和Kaplan - Meier法绘制的累积生存曲线和术后心肌梗死曲线显示，随访13年后两组之间无统计学显著差异。研究组新发心绞痛的发生率较低（p < 0.01）。大多数患者身体状况良好，能很好地耐受运动试验（Bruce方案），射血分数无明显受损。
尽管冠状动脉内膜切除术历史悠久且不断发展，但它仍是心脏外科中最具争议的方法之一。该方法的应用非常受限，主要是因为其复杂性以及不同机构之间结果差异很大。第一间隔动脉的内膜切除术手术风险最高，但它是该区域完全血运重建的首选方法。尽管手术死亡率较高，但本研究的近期和长期结果表明，冠状动脉内膜切除术是一种手术风险非常可接受的方法。
内膜切除术是弥漫性冠状动脉疾病患者直接心肌血运重建的一种良好且有效的方法。它是间隔血运重建的最佳手术。内膜切除术的数量和低射血分数是早期和长期死亡率的独立预测因素。内膜切除术也是射血分数低和冠状动脉床差的患者的首选方法。血管成形术的频繁和重复应用、弥漫性和远端冠状动脉疾病的发生率增加以及心脏移植无可用供体将增加该方法的应用。未来我们期望冠状动脉内膜切除术能进一步改进并得到完全认可。
